12/10/10
Anything Boys can do, Girls can do
Better
Sports Injuries
Anthony Luke
MD, MPH, CAQ (Sport Med)
University of California, San Francisco
Controversies in Women’s Health
December 5, 2008
Title IX 1972
High School Participation Rates
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Vancouver2010
The Locked Knee
Bucket handle meniscus
(usually medial)
ACL tear/stump
Effusion
Loose body/ Osteochondritis
Dissecans
Osteoarthritis
Pseudolocking (usually MCL
sprain)
The Women’s Marathon
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Marathon Records
Attainment of Peak Bone Mass
(PBM)
♀ at Risk: Hyponatremia
Risk factors:
• Racing time > 4 hours
• Female sex
• Low Body Mass Index 3 liters
• Postrace weight > prerace
weight
– Almond et al., N Engl J Med,
2005.
Other mechanisms?
• Hormonal, excessive salt
loss
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Physical inactivity
• Females more
inactive than males
• 27% of girls
(12-14 y.o.) are inactive
• 48% of girls
(15-19 y.o.) are inactive
Overview
• Common sports
injuries for women
– Knee problems
– Bone problems
• Issues for the female
athlete
History is Key
What? Pain
Instability Dysfunction
• Numbness
• Fever
• Swelling
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Q1 Do female athletes get more
ACL injuries than male athletes?
1) Yes, because women play harder
2) No, people just say that
3) Yes, because of anatomical problems
4) Yes, because of endocrine differences
5) Yes, because of muscle control
differences
What you Knee’d to know
• Women have more
knee problems
• Miserable
malalignment
syndrome
– Femoral anteversion
– Genu Valgum
(knocked knees
– Pes planus (flat feet)
Anterior Cruciate Ligament (ACL)
Tear
Mechanism
• Landing from a
jump, pivoting or
decelerating
suddenly
• Foot fixed, valgus
stress
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Anterior Cruciate Ligament (ACL)
Tear
Theories
• Hormonal
• Notch size
• Alignment
• Flexibility
• Neuromuscular
control *
• Women’s sports
Anterior Cruciate Ligament (ACL)
Tear
Symptoms
• Audible pop heard or felt
• Pain and tense swelling in
minutes after injury
• Feels unstable (bones
shifting or giving way)
Double fist sign
Acute Hemarthrosis
1) ACL (almost 50% in children, >70% in
adults)
2) Fracture (Patella, tibial plateau, Femoral
supracondylar, Physeal)
3) Patellar dislocation
• Unlikely meniscal lesions
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ACL physical exam
LOOK
• Effusion (if acute)
FEEL
• “O’Donaghue’s Unhappy Triad”
= Medial meniscus tear, MCL
injury, ACL tear
• Lateral meniscus tears more
common than medial
• Lateral joint line tender -
femoral condyle bone bruise
MOVE
• Maybe limited due to effusion
or other internal derangement
Special Tests ACL
• Lachman's test – test
at 20°
(Sens 81.8%, Spec 96.8%)
• Anterior drawer – test
at 90°
(Sens 40.9%, Spec 95.2%)
• Pivot shift
(Sens 81.8%, Spec 98.4%)
(Katz JW, et al., Am J
Sports Med, 1986)
Special Tests ACL
• Lachman's test (Sens
81.8%, Spec 96.8%)
• Drop Lachman
• Anterior drawer
(Sens 40.9%, Spec
95.2%)
• Pivot shift
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X-ray
• Usually non-
diagnostic
• Can help rule in or
out injuries
• Segond fracture –
avulsion over
lateral tibial plateau
MRI
• Sens 94%, Spec 84%
for ACL tear
ACL tear signs
• Fibers not seen in
continuity
• Edema on T2 films
• PCL – kinked or
Question mark sign
MRI
• Sens 94%, Spec 84%
for ACL tear
ACL tear signs
• Lateral femoral corner
bone bruise on T2
• May have meniscal
tear (Lateral > medial)
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ACL Tear Treatment
Conservative Surgery
• No reconstruction • Reconstruction
• Physical therapy • Depends on activity
• Hamstring demands
strengthening
• Proprioceptive training • Recovery ~ 6 months
• ACL bracing
controversial
• Patient should be
asymptomatic with
ADL’s
To Fix or Not to Fix ?
No repair
• 1/3 do well, 1/3 go on decide to get surgery, 1/3 do
poorly and need surgery
Surgery
• Reconstruction is treatment of choice
• Repair allows them to return to sports
• Reduce chance of symptomatic meniscal tear
• Less giving way symptoms
• Wait until patient skeletal maturity
ACL Reconstruction
• More predictive return
to sports
• Grafts
– Patellar tendon
– Hamstring
– Allograft (Cadaver)
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ACL prevention program
• Prevent Injury and Enhance Performance
(PEP) Program
• 74% reduction in anterior cruciate ligament
tears over 2 years
Mandelbaum et al., Am J Sport Med, 2005
• 1.15 injuries per team per season when
trained vs 0.15 injuries per team per
season (RRR=0.13)
Caraffa et al., Knee Surg Sports Traumatol Arthrosc, 1996
Rehab, Rehab, Rehab
• Control Pain
• Improve range of
motion
• Regain strength
• Restore function
• Sports Specific Ankle Alphabets
exercises
• Return to activities /
play
• PREVENTION!
Patellofemoral pain
• Too much pressure
under the kneecap
Symptoms
• Anterior knee pain
• Worse with bending (5x
body wt), stairs (3x body
wt)
• Crepitus under kneecap
• May sublux if loose
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Patellofemoral Pain
• Multifactorial
Problems with:
• Bending?
• Stairs?
• Kneeling?
• Need good muscle
balance
• Quadriceps strength
• Good flexibility
PFP Syndrome
• Tender over facets of
patella
• Apprehension sign
suggests possible
instability
• X-rays may show
lateral deviation or tilt
Patella
• Deviate patella to palpate to palpate
lateral, medial and inferior facets
• Check patellar mobility
• Check tightness of the retinaculae/
patellar tilt
• Apprehension test
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Look (Standing)
• Alignment
• Ankles together
• Ankles apart
• On toes
• Walk
• Red flag – can’t do it
• Hop test
Think Biomechanics
• Alignment
• Consider orthotics
• “Relative” symmetry
• Control running
• Worry when running
technique alters
One Leg Squat
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Arch type
Q-angle
Too Loose?
Hyperlaxity
• Associated with
subluxation of the
patellae
• Medial facet more
commonly affected
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Too Tight?
• Lateral hyperpressure
syndrome
• Tight hamstrings,
ilotibial bands, high
flexors and
quadriceps
Treatment PFP
Too Loose/Weak Too Tight
• Strengthen VMO • Stretch hamstring,
• Strengthen gluteals quadriceps, hip flexor
• Correct alignment • (Strengthen quads)
• Support (Taping, • Correct alignment
Bracing) Surgical (RARE)
• Last resort
• Lateral release
• Patellar realignment
Iliotibial band friction syndrome
• 10-21% of running
overuse injuries
• ITB crosses the
lateral femoral
epicondyle at 30°
• Associated with
“varus” moment at the
knee
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ITB Syndrome
Fix the underlying
problems
• ITB Stretching
• Hip abductor / gluteal
muscle strengthening
• Medial quadriceps
strengthening exercises
• Correct alignment
• Modify training
Stay Flexible and Strong
Key muscle groups
• Hip Flexor, ITB,
Hamstring,
Quadriceps, Calf /
Achilles
• Hold each stretch for
30 seconds
• Core stability /
Strengthening
Q2 28 y.o. woman presents with joint “clicking”
and soreness in the shoulders, knees, wrists,
elbows, ankles etc. for years. She looks generally
healthy. She is most likely:
1) Rheumatoid arthritis
2) SLE
3) Fibromyalgia
4) Ehlers Danlos
5) Munchausen’s Syndrome
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What is “Normal” Flexibility?
• Flexibility is the range of
motion available at a joint
or series of joints
• Hypermobility vs.
Hypomobility
• Spectrum like
hypertension
Generalized Laxity
Modified Marshall Test
Micheli Score
• Look at passive thumb
abduction of the right hand
• Grade 1 = 0°
• Grade 2 = 45°
• Grade 3 = 90°
• Grade 4 = 135°
• Grade 5 = thumb touches
forearm
• Can use + or – for in
between grades
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Common Pictures
Hyperlaxity Tight
• OVERUSE & Postural • Patellofemoral
problems syndrome, hamstring
• Associations with and quad strains
subluxation of the hip, • Tendinopathies
patella, shoulder, and • Osgood-Schlatter’s
proximal cervical disease, Sever’s
spine, osteoarthritis, disease and peripelvic
chondrocalcinosis, apophyseal avulsion
• Bad sprains fractures
Multidirectional instability
Subtalar Tilt test
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Rehab, rehab, rehab
Strengthening
• Core stability
• Postural exercises
– Upper Back
• Proprioception exercises
• Endurance / conditioning
• Ergonomic assessment at
work
? Chronic pain
Q3 A 16 y.o. ♀ X-country runner runs 60 miles/week.
She weighs 95 lbs and is 5’2”. She presents with B
shing splints and has had 3 stress fractures. She has
not had a period yet. What do you need to do?
1) Send her to a psychiatrist to find out why find
out why she runs so much.
2) Put the athlete on the birth control pill due to
amenorrhea
3) Nothing. It’s OK because she’s an athlete.
4) MRI to see if she needs crutches.
5) Put her on calcium and vitamin D for
osteoporosis.
What are the risk factors?
Gait Mechanics Training
BONE
LOADING
Bone Health Impact
Brukner P, Bennell K, Matheson G. Stress fractures, Blackwell Science, 1999.
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How stress fractures occur?
• Failure of bone to
adapt to stress
• Microinjury/
microcracks in the
bone
Diagnosis
History Physical exam
• Pain with loading/ • Localized bone
stressing bone (i.e. tenderness +/-
running, jumping, swelling
etc.) • Antalgic gait
• May have history of • Unable to hop
new activity or
increased training
Diagnosis
X-ray
• Periosteal thickening
(takes > 2 weeks to
appear)
• Fracture line
Bone Scan
MRI
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When to return to sports
• N=53
• Length of recovery and
MRI Grade 1-4
Pearson r= 0.627, p=
0.001)
• Grade 3 takes 12
weeks, Grade 4 takes
16 weeks
• Bone remodeling takes
around 180 d
Traction vs. Compression
Stress Fractures
• Tibia –medial, anterior*
• Foot – metatarsal shafts or base of 5th
metatarsal (metaphysis – Jones fracture*)
• Spine – Spondylolysis L5 pars
interarticularis*
• Pelvis – pubic rami, ischial tuberosity
• Femoral neck*
• *- denotes high risk of non-union
Tibial Stress Fractures
• Activity modifications
(painfree)
• Pneumatic brace
• May take up to 12-16
weeks to recover
• Anterior “dreaded black
line” stress fracture
• Unload bone
• May require surgery if no
healing in 8-12 weeks
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Femoral Neck Stress fracture
• MRI 100% sensitive
(gold standard)
Shin et al. AJSM, 1996
• Crutches with non-
weightbearing x 2-4
weeks; then protected
weightbearing x 6-8
weeks
Avulsion of the Base of the 5th
Metatarsal
• Due to pull of
peroneus brevis
• Most common foot
fracture (90%)
Treatment
• May treat
conservatively as a
sprain
• Usually heals in
around 6-12 weeks
Jones Fracture
• May go on to non-
union
• Treat with
immobilization for
8-12 weeks
• May require ORIF
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Bone Development
• Greater than 90% of peak bone mass is
most likely present by 18 y.o.
• Bone density ↑ by 6-8% each year
especially during puberty
• Skeletal age 10-14 appear most important
for bone acquisition and is linked with
maximal rate of growth
Sabatier et al, Osteoporosis Int, 1996
Q4 The female athlete triad is:
1) A condition involving obsessive
compulsive behavior
2) A primary endocrine disorder affecting
estrogen levels
3) A condition related to an eating disorder
4) A deficiency disorder due to lack of
calcium and vitamin D
5) Asian gang members who enjoy exercise
Female Athlete Triad
Amenorrhea
(Loss of periods)
Osteoporosis
Disordered Eating
(Thin Bones)
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Female Athlete Triad
Warning Symptoms
• Often presents with recurrent
stress fractures
• Irregular periods or delayed
menarche
• Vegetarian at young age
• Avoids eating with others or skips
meals
• Trains excessively
• Using dieting methods
inappropriately
Management: Amenorrhea
Work up
• B-Hcg
• LH/FSH
• sTSH
• PRL
• Consider Oral contraceptives
Management: Osteoporosis
• DEXA bone density
• Effects on BMD may be irreversible
• Increased risk of stress fractures if low
BMD
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Nutrition
• Must have enough fuel to
maintain amount of
activity
• 1800 to 2500 calorie/day
• Athletes NEED MORE !!!
Fueling Up
• Carbohydrates (55% of
energy)
– 1.5 g per kilogram body
weight per day
• Protein
– 1.2-2 g/kg weight
• Eat a good breakfast
• Snacks before practice
especially if it’s late
Vitamin D and Calcium
• 18 Australian elite
gymnasts were surveyed
• 15 were below 75 nmol/L
• 6 were below 50 nmol/L
• 13 also had dietary Ca
intakes below
recommended for age
• Daily dietary calcium
intakes averaged 823 mg
(range 240-1740 mg)
Lovell, CJSM,
2008
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Nutritional factors
• Calcium
– If poor diet or low bone
density
– 1200-1500 mg/d
• Vitamin D
– Deficiency common?
– 800 IU/day
– Get sun
• Iron
Make ours doubles
Management:
TEAM approach
• Psychologist / psychiatrist
• Nutritionist
• Family
• Coach
• Sports Physician
• Family Physician
• OB/GYN
Are “Sports” part of the problem?
• Aesthetic sports
• Excessive training hours
• Win at all costs
• Steroids
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Take Home “Pointes”
Check
• Activity levels
• Anatomy
• Flexibility
• Nutrition
• Hormone
• Psychological – Are
you having fun?
6th UCSF Primary Care Sports Medicine
conference
Grand Hyatt, Downtown SF
December, 2011 in San Francisco
Prevalence of Triad
• 91 Runners - > 40 miles/week
• 6% of oligomenorrheic and/or
amenorrheic runners were
osteoporotic, and 48% were
osteopenic
• 26% overall had BMD that
could be called osteopenic
• Even in runners who were
menstruating – low BMD
scores were observed if they
had evidence of disordered
eating
Cobb et al., MSSE 35:711-719, 2003
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Evidence??
• Overall positive effect
– Lanou et al. Pediatrics 2005
• Lumbar and hip BMD
increases of 1.5%
– Shea et al. Endocr Rev 2002
• Addition of 800 mg/day
calcium to diet of young
distance runners with intake
of 1000 mg/day prevents
cortical but not trabecular
bone loss
– Winters-Stone & Snow Int J Sport
Nutr and Exerc 2004
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